PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES Evaluation and Management of Hyperbilirubinemia in the Newborn Nursery and NICU © Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES Clinical Guideline Name Evaluation and Management of Hyperbilirubinemia in the Newborn Nursery and NICU Implementation Date March 1, 2016 Due for CPC Review Contact Person Medical Director, NICU Approved By Department of Pediatric Newborn Medicine Clinical Practice Council _1/14/16_____ CWN PPG 1/13/16_____ BWH SPP Steering 2/17/16__________ Nurse Executive Board/CNO_2/22/16____ I. Purpose The purpose of this clinical practice guideline is to ensure that all infants receive optimal and consistent care for hyperbilirubinemia by establishing standard practices for the evaluation and management of hyperbilirubinemia in preterm and term infants. II. All CPGs will rely on the NICU Nursing Standards of Care. All relevant nursing PPGs are listed below (all underlined text is hyperlinks): WNH P.1 Phototherapy for Infants WNH B.8 Infant Bilirubin Screening WNH B.2 Infant Heelstick Blood Sampling WNH ---- Care of the Late Preterm Infant IVIG DAG III. Scope These guidelines apply to all infants in the care of the Department of Pediatric Newborn Medicine. The guidelines include recommendations for evaluation, diagnosis and monitoring of hyperbilirubinemia, as well as indications for administration of phototherapy, intravenous immunoglobulin (IVIG) and exchange transfusion. IV. Etiology and Evaluation Every infant with jaundice should be evaluated for etiology and severity of hyperbilirubinemia to guide appropriate therapy For jaundice appearing on o Day 1: consider isoimmunization (ex. Rh, ABO incompatibility) and congenital infection . If mother is blood type O+, obtain infant blood type and direct antiglobulin test (DAT) © Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES o Days 2-6: consider bacterial infection (including urinary tract infection), resorption jaundice (ex. cephalohematoma), metabolic disease (ex. galactosemia), isoimmunization, congenital infection, breastfeeding jaundice/dehydration, physiologic jaundice, RBC membrane defects (ex. spherocytosis), RBC enzyme defects (ex. G6PD deficiency, pyruvate kinase deficiency) . Obtain blood type, DAT, hematocrit, reticulocyte count, and blood smear . If hemolysis is present with negative DAT, check RBC enzymes . If elevation of direct bilirubin, obtain urinalysis and urine culture and evaluate causes of cholestasis o Days 7+: . Indirect (unconjugated) hyperbilirubinemia: consider breast milk jaundice, hypothyroidism, sepsis . Direct (conjugated) hyperbilirubinemia: evaluate causes of cholestasis Jaundice appearing within 24 hours of life is pathologic until proven otherwise It is crucial to determine presence or absence of hemolysis The total serum bilirubin (TSB) level is used when determining levels for phototherapy or exchange transfusion Physiologic hyperbilirubinemia is a diagnosis of exclusion. Persistent hyperbilirubinemia in an non-breast fed infant should be considered abnormal, and warrants further investigation V. Assessing risk a. Major risk factors for developing severe hyperbilirubinemia: o TSB in the high risk zone of the Bhutani nomogram o Jaundice observed in first 24 hours of life o Blood group incompatibility (Rh or ABO) or known hemolytic disease o If mother is blood type O+, obtain infant blood type and DAT o Prematurity o Cephalohematoma, subgaleal hemorrhage, or other significant bruising o Previous sibling with hyperbilirubinemia requiring phototherapy o Exclusive breastfeeding, particularly in setting of excessive weight loss o East Asian race b. Use of nomograms: Nomograms help assess risk for developing hyperbilirubinemia and assist in determining the timing of appropriate follow-up Bhutani curve (below) is the accepted nomogram for assessing hyperbilirubinemia risk for infants ≥ 35 weeks gestation, based on bilirubin level and postnatal age © Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES Bhutani nomogram (≥ 35 weeks gestation): Bhutani et al. nomogram for well newborns at >36 weeks’ gestational age with birth weight of >2000 g or more or >35 weeks’ gestational age and birth weight of >2500 g based on hour-specific serum bilirubin values. c. Bilitool: Bilitool (www.bilitool.org) is a web site that provides a free, user-friendly, interactive way to match infant bilirubin levels with the Bhutani nomogram and established phototherapy guidelines (for infants ≥35 weeks) VI. Light source and irradiance Blue fluorescent lamps or LED systems (ex. neoBLUE®) provide irradiance in the 430 – 490 nm band and are determined to be the most effective light source for phototherapy o LED lights provide the greatest TSB decrease during first 24 hours, followed by spotlights, bank of lights, and blankets If TSB continues to rise despite phototherapy, consider increasing irradiance by bringing phototherapy lamp closer to infant or increasing body surface area exposed to phototherapy (ex. place additional light source beneath infant and reflecting material around incubator or radiant warmer) Use radiometer recommended by manufacturer of phototherapy system to measure irradiance (Biomed) © Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES Due to increased mortality associated with phototherapy use in ELBW infants, if BW < 750g, consider initiating phototherapy at lower irradiance level (i.e. “low” setting) and only increase irradiance (or surface area exposed) if TSB continues to rise VII. Infants ≥ 35 weeks gestation a. Key points: TSB levels progressively increase during the first 96-120 hours after birth and usually decline depending on the maturation of the infant’s liver, initiation of enteral feeds, motility Irradiance Device Location Notes (uW/cm2/nm) Output depends on distance from lens to infant Giraffe Spot PT Lite (GE) 6-35 NICU Utilizes white light To be discontinued by GE and replaced with blue LED spotlights Both low and high settings assume 12-15 (low) NICU, distance of 12” from light to infant NeoBlue (Natus) Newborn Nursery 30-35 (high) Utilizes blue LED 70 (small pad) BiliSoft Blanket (GE) NICU Utilizes blue LED 49 (large pad) NeoBlue Cozy Bed (Natus) 30-35 Newborn Nursery Utilizes blue LED BiliBed (Medela) 40-60 Newborn Nursery Utilizes blue fluorescent tube 15 (low) BiliBlanket Plus NICU, 25 (medium) Used rarely in NICU (Datex-Ohmeda) Newborn Nursery 35 (high) of the GI tract, and infant’s ability to clear the bilirubin load i. Note: TSB levels in late preterm infants may peak later (as compared with term infants), and rate of rise may be steeper Jaundice should resolve by 2 weeks of life in most infants; persistent jaundice beyond age 2 weeks warrants further investigation b. Bilirubin measurement: Initial transcutaneous bilirubin (TcB) measurement should be obtained around the time of the initial newborn screen (between 24-48 hours of life) o Note, if mother is blood type O+ and Coombs is positive, TcB should be obtained at 12 hours of life and further close follow-up recommended If TcB level is above the threshold (use table below), obtain a serum bilirubin (TSB) Postnatal age Threshold transcutaneous bilirubin level (hours) (mg/dL) 24-36 h 7 © Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES 8 37-48 h 49-72 h 10 72-96 h 12 96+ h 14 If major risk factors are present (see below), or if infant appears jaundiced, consider obtaining initial TcB at earlier time point Note: in NICU setting, consider obtaining TSB (instead of TcB) to coincide with scheduled blood draw Note: TcB measurement may be used on infants of any race or ethnic background but results may be mildly affected by skin pigmentation o TcB typically overestimates TSB in infants who are dark-skinned, and likely underestimates TSB in light-skinned infants c. Risk factors for bilirubin toxicity: Hemolysis G6PD deficiency Asphyxia Neurological signs including significant lethargy or irritability Temperature instability Confirmed or suspected sepsis Acidosis Hypoalbuminemia (< 3 g/dL in near term and term infants) d. Phototherapy: Guideline for initiating phototherapy (≥ 35 weeks gestation) © Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES e. Ongoing monitoring: Obtain daily morning (04:00) TcB until downtrending If TcB level is above the threshold (use table in section VII. b above), obtain TSB Once phototherapy has been initiated: o Follow serial TSB levels (TcB levels will no longer be accurate) o Repeat TSB in 12-24 hours after starting phototherapy o For bilirubin levels approaching exchange level or rapid rate of rise more frequent bilirubin measurements are recommended o Use bilitool.org for specific recommendations regarding timing of serial TSB measurements Decisions regarding when to discontinue phototherapy should be based on the infant’s individual risk factors and clinical situation Measure bilirubin within 12-24 hours after phototherapy is discontinued, then as clinically indicated (i.e. in setting of ongoing hemolysis) Consult with neonatologist if TSB is within 2 mg/dL of exchange transfusion threshold,